Provider Demographics
NPI:1932576485
Name:BELLHORN, TRACY
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:BELLHORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 N MICHIGAN AVE STE 5
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4751
Mailing Address - Country:US
Mailing Address - Phone:989-552-5910
Mailing Address - Fax:
Practice Address - Street 1:1320 N MICHIGAN AVE STE 5
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-4751
Practice Address - Country:US
Practice Address - Phone:989-552-5910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802087505171M00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI171M00000XMedicaid
MI1932576485Medicaid